Service Evaluation of Scotland's Take-Home Naloxone Programme

3 Programme processes and structures

3.1 This chapter provides a description of the main processes and structures of the THN programme in Scotland based on the information provided by local naloxone coordinators, SPS staff and NHS staff working in prisons, and from publicly available statistics from ISD.

Coordination and support nationally for the programme

3.2 The THN programme is coordinated, guided and monitored at national level by the expert members of the National Naloxone Advisory Group which has representation from a range of organisations.^[10]

3.3 The Scottish Government's role in this programme supports:

• a National Naloxone Coordinator and a National Training and Support Officer based at the Scottish Drugs Forum (SDF);
• the development of national information and training materials including a website (www.naloxone.org.uk);
• reimbursement to NHS Boards for the THN kits issued in their area;
• an in-depth monitoring and evaluation programme, including measuring progress against a baseline measure, is delivered by the Information Services Division (ISD) of NHS National Services Scotland. ISD has produced two annual monitoring reports to date (2011-12 and 2012-13) and it provides quarterly reports to the National Naloxone Advisory Group so that its members can assess progress;
• specific support for the roll out of the programme in prisons.

3.4 In addition a specific monitoring indicator has been established for the programme: a decrease in the number of opioid-related deaths and opioid related deaths within 4 and 12 weeks of release from prison.

3.5 Increasing the reach and coverage of THN has been a Ministerial priority for Scotland's Alcohol and Drug Partnerships (ADPs) in 2013-14 and will continue for 2014-15.

3.6 In 2013/14, expert advice received from Scotland's National Naloxone Advisory Group suggested that between 1 April 2013 and 31 March 2014:

• a minimum of 15% of people with problem opioid use should be supplied with THN.
• all clients receiving prescribed opioid substitute treatment should be offered a THN kit.
• all those discharged from hospital with problem opioid use should receive a THN kit.

3.7 The Scottish Naloxone Network (ScoNN) is a forum for local naloxone coordinators to share good practice, receive updates on current policy developments, and 'troubleshoot' relevant issues. All 13 of the Health Boards involved have membership on the ScoNN Group, with 12 regularly attending. It meets in parallel with the NNAG (usually a fortnight before) and was originally chaired by NHS Health Scotland and more recently by SDF.

3.8 Staff at SDF provide a two-day Training for Trainers programme (which many Boards have participated in, see below) and a four-day National Naloxone Peer Education Programme, for people who use (or formerly used) drugs and wish to become peer educators/trainers.

3.9 Appendix 3 sets out the quantitative information gathered from the research process. It provides key statistics relating to DRDs and the number of naloxone kits issued, alongside key elements of each local naloxone programme. Table 3.1 below, provides a summary of this information covering key statistics relating to DRDs, number of naloxone kits issued, alongside key elements of each Health Board THN programme.

Table 3.1: THN programme - summary service mapping (Snapshot of figures Aug 2013 unless otherwise stated)^[11]

		Health Board													Total
		Ayrshire & Arran	Borders	Dumfries & Galloway	Fife	Forth Valley	Grampian	Greater Glasgow & Clyde	Highland	Lanarkshire	Lothian	Orkney	Shetland	Tayside
No. of people with PDU aged 15 - 65 in 2009/10 [12]		5,100	580	1,300	3,300	2,200	4,900	20,800	2,100	5,900	8,200	0	130	5,000	59,510
No. of DRDs in 2012[13]		43	7	6	38	31	31	193	22	61	90	1	2	55	581
No. of THN kits issued in the community Apr 2011 - Mar 2013 [14]		734	219	89	381	225	200	1,498	687	448	951	0	18	380	5,830
No. of THN kits issued In the community (2011/12 and 2012/13) per 1,000 estimated people with PDU aged 15 - 64 [15]		143.9	377.6	68.5	115.5	102.3	40.8	72	327.1	75.9	116	0	138.5	76	N/A
No. of THN kits issued to prisoners on liberation Apr 2011 - Mar 2013 [16]		54	N/A	99	N/A	449	48	299	132	17	199	N/A	N/A	164	1,461
Programme start date		2011	2011	2010	2011	2011	2011	2007	2009	2007	2011	2013	2011	2011	N/A
Local steering group		No	Yes	Yes	Yes	Yes	No	Yes	No	Yes	No	Yes	Yes	Yes	N/A
Local trainers forum		Yes	No	No	No	Yes	No	No	Yes	Yes	No	Yes	No	Yes	N/A
Peer trainers		Yes	No	No	Yes	Yes	No	Yes	Yes	Yes	Yes	No	No	Yes	N/A
Participation in ScoNN		Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	No	Yes	N/A
No. of staff trained	Voluntary sector	27	8	20	17	20	43	54	14	1	18		4	6	232
	Statutory sector	37	12	20	50	39	5	158	24	62	58	1	2	68	536
	Pharmacy staff			1	13	1	10	80		2					107
	Peers[17]	5			10	4	4	28	9	10	15			4	89
	Others	9	3		25	5	6	33	5	11	1	2	2	12	114

Summary of community based THN programme

Delivery model

3.10 The national THN programme is operational within all Scottish territorial NHS Boards except Western Isles which has chosen not to participate. All Boards except one utilise a partnership model for the delivery of the programme, involving both the statutory and voluntary sectors. Six Boards make use of community pharmacies for training and/or supply. A PGD permits nurses or pharmacists to supply naloxone to people at risk of overdose.

3.11 Each Board has at least one named local naloxone coordinator to support the THN programme locally.

3.12 The primary naloxone delivery route in Scotland's national programme is through intramuscular administration. (In Highland intranasal naloxone is being piloted locally by the NHS Board in response to local assessments of naloxone 'saturation' and the need to find a non-needle based approach within the NHS Board area.)

3.13 In addition to the nationally produced materials, six Health Boards have also produced their own materials. Locally produced materials ranged from Health Board specific issues (such as intranasal administration in Highland), to materials that had been developed locally but which have since been rolled out nationally (such as the 1:1 training checklist, and local guidance for non-statutory services developed in Greater Glasgow & Clyde).

Management and accountability at a local level

3.14 Nine Health Boards have a naloxone steering group (or equivalent), while four have no comparable structure. Local naloxone coordinators report that strategic leadership is important for adding credibility and strategic weight to the programme.

3.15 All local THN programmes work with their local ADPs (29 out of 30 are engaged). However according to the local naloxone coordinators, the nature of the relationship between local programmes and their respective ADPs is variable. Some ADPs take an active leadership role, while others tend to defer to the role of the Health Board.

3.16 The THN programme is locally monitored either by the steering group or by the local naloxone coordinator.

Staff training

3.17 There are regular programmes of TTT for staff in most Health Boards (usually twice a year) provided by either SDF staff and/or local trainers. The training course generally lasts between one and two days, sometimes with required pre-reading before the course. Since the start of the programme, there has been a shift towards shorter courses and towards the use of local trainers.

3.18 According to the online survey of responses from local naloxone coordinators, a total of 536 addiction/treatment staff have been trained in the statutory sector, 232 in the voluntary sector, and 107 community pharmacists and pharmacy support staff since the national programme began. Information provided by national naloxone programme support staff indicates that 89 peer trainers/educators have been trained (but may not all be operational as some may have moved on from training). A range of other professions have received training, for example GPs, homeless provision staff, and criminal justice staff. Low numbers of police and ambulance service personnel have been trained as part of the THN programme (although they may have received training through their own training programmes).

Training and supplying people with problem drug use

3.19 Training and supply of people who use drugs is undertaken in all 13 participating Health Board areas. Training is offered by staff from both voluntary and statutory sectors, with supplies being made under the PGD primarily by nursing staff. In the six areas where community pharmacies are participating in the programme, supplies are also made here.

3.20 A total of 5,830 THN kits (which includes those given to people at risk, service workers and family/friends) were distributed in the community during years 2011-12 and 2012-13. This represents just under 10% of the total estimated number of problem drug users in Scotland (59,510). However it should be noted that these were not all first-time supplies but include re-supplies as well. There were 910 repeat supplies out of this total figure (and a further number where it was unknown if they were a first or repeat supply).^[18] This means that the actual 'reach' to people with problem drug use within the community is lower, around 8%. (If the number of kits distributed to prisoners at liberation is included the total number of kits given out is 7,291, taking the percentage of those at risk of overdose reached to just under 11%.)^[19]

3.21 Local naloxone coordinators reported a noticeable shift from an initial group model of training service users to a 1:1 model, often referred to as a brief intervention, with a consequent reduction in the time taken for this (often 10 - 30 minutes). This compares with the duration of the group sessions which could last up to two hours.

3.22 Local coordinators also reported that the training and supply of naloxone to people who use drugs was increasingly being integrated into regular service provision such as support and advice, needle exchange and opiate replacement therapy.

Summary of prison based THN programme

3.23 SPS was approached by the Scottish Government in 2010 to scope the implementation of the naloxone programme in prisons to those at risk of opioid overdose following liberation. The programme was introduced incrementally from February 2011. The training of prisoners began in April 2011 and by June 2011 all prisons were participating in the programme.

3.24 A Governors and Managers Notice was issued to all prisons in 2010 prior to implementation of the programme. Governors and Managers notices providing further information and guidance for staff were issued during June and August 2011. A Guidance Manual for Staff (2010, revised 2011) was also issued to all prisons. Information notices on the naloxone programme continue to be issued to prison staff when additional information or updates are required to be provided.

Delivery model

3.25 Prisoners are offered naloxone training on a voluntary basis as close to their date of liberation as possible. Following completion of the training a naloxone supply is placed in the prisoner's property for collection on liberation.

Management and accountability

3.26 Until November 2011, the delivery of the THN programme in prisons was the responsibility of SPS. From November 2011 responsibility for the delivery and governance of the naloxone programme in prisons transferred to local Health Boards in line with the overall transfer of prisoner healthcare from SPS to the NHS.

Staff training

3.27 Prior to November 2011, 100 staff (both clinical and Enhanced Addiction Caseworkers) were trained in all establishments.

Training and supplying people with problem drug use

3.28 Training is undertaken on a voluntary basis following assessment. This takes place on either a group or a 1:1 basis.

3.29 A total of 1,461 THN kits have been distributed to prisoners on release from prison during years 2011-12 and 2012-13.^[20]

3.30 It has not been possible to ascertain national figures for prisoners on opiate replacement therapy programmes in Scottish prisons (and hence an estimate of the effective 'reach' of the naloxone programme in prisons). We understand, however, from SPS that Healthcare Improvement Scotland is currently undertaking a consultation with Health Boards (during March 2014) to ascertain the number of Scottish prisoners being prescribed opiate replacement therapy across all Health Boards.

Information across both community and prison settings

3.31 We asked respondents in the online survey to tick all locations in which they had supplied naloxone. Table 3.2 below shows that 65% of those who responded supplied naloxone in NHS clinics, 23% at voluntary sector agencies, 20% at community centres/facilities, 15% at pharmacies, 15% at people's homes, 11% in prison, and 10% at another outreach location.

Table 3.2: Setting in which naloxone is supplied

3.32 There are four core models of training and supply of naloxone to people with problem drug use based on the four key places where training and supply may take place: drug treatment centres; prison; outreach services; pharmacies. Table 3.3 below outlines these.

3.33 The use of peer trainers is increasingly being used across Health Boards for the training of service users. SDF provides national support and coordination for this. To date, 76 peer trainers have been trained by the four-day training programme for peer educators delivered by the national naloxone team across six Health Boards (from figures provided by the national naloxone team) and two further Health Boards in the survey report having peer trainers who have been trained through the TTT. Two prisons have peer trainers in place: one prison has a peer education network with 11 peer educators trained and another has one peer trainer. Peer trainers have trained 293 people, and facilitated access to naloxone supplies for 204 people across eight Health Boards. In one prison all the naloxone training is delivered by peer trainer.

Table 3.3: models of THN programme delivery

		Drug treatment agency	Prison	Outreach	Pharmacy
Training	Where	Statutory services (eg NHS clinics, Community Addictions Teams, Injecting Equipment Providers, residential centres) Voluntary sector agencies (eg drug projects, community rehab)	Prisons	Partner organisations (eg hostels) Mobile buses Homes of people with drug problems	Community pharmacies
	By whom	Nursing staff Non-clinical staff Peer trainers	Nursing staff (based in prison) Enhanced Addiction Casework Service (EACS) staff Peer trainers	Nursing staff Non-clinical staff Peer trainers	Community pharmacists Community pharmacist support staff Peer trainers
	Method	Group sessions (< 2 hours) 1:1 sessions / brief intervention (10 - 30 minutes)	Voluntary sessions (both group and 1:1) as part of drug treatment programmes	Flexible, in response to circumstances / brief intervention	1:1 sessions / brief intervention (10 - 15 minutes)
Supply	Where	As above	As above	As above	As above
	By whom	Nursing staff	Nursing staff	Nursing staff	Pharmacists
	Method	Either following training, or at agreed later point	Supply issued to prisoner on liberation	Either following training, or at agreed later point	Following training Some supply only, if evidence of training elsewhere provided

Summary of main points

3.34 The programme has put in place structures and systems to allow staff from both the statutory and voluntary sectors who work with people at risk of overdose, as well as peer trainers in some Health Board areas, to be trained in how to provide knowledge and skills about naloxone, and how to administer it, to people with problem drug use. The supply of naloxone is mainly administered by nurses or pharmacists (where the latter are participating in the programme). In prisons the kit is supplied by placing it in the person's property prior to liberation (if they agree to this after training).

3.35 5,830 kits were distributed in the community setting (including to people at risk, service workers and family/friends) between 2011 and 2013, and this is approximately 8% of the total population of people with problem drug use. It highlights that while a start has been made, there is still much to be done to increase the reach to all those who might benefit. Likewise the number of kits distributed in prisons (1,461) appears low and ways to increase the take-up of naloxone training and kits for former prisoners at risk need to be explored.